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A follow-up study of surgically treatedcryptorchid patients
A Follow-up Study of Surgically Treated Cryptorchid Patients By P. M. Atkinson
PERATIONS FOR C R Y PT O R C H I S M have an unusual feature in that although the initial anatomic result of orchiopexy is immediately apparent, the functional result of operation may not be known until about 15 or more years later. The study of further series of adults who have had orchiopexies during childhood will help to overcome this remoteness between childhood operation and eventual functional result. The patients in this study came from a limited source of two childrens hospitals in the South of England. A different technique of orchiopexy was used at each of the two hospitals, but the surgeons at both hospitals were aware of the patient with a retractile testicle who will have been largely excluded from the study.
O
MATERIAL AND METHODS
An attempt was made to trace 207 patients who had had childhood orchiopexies at either Paddington Green Children's Hospital, London (P.G.), or Queen Mary's Hospital for Children, Carshalton, Surrey (Q.M.). The operations had been performed between the years 1939 and 1962. Four surgeons or their deputies performed the operations. The majority of patients at P.G. had had Ombredanne's method of orchiopexy? placing the mobilized testicle through the septum into the opposite side of the scrotum. The patients from Q.M. had had the Denis Browne technique of orchiopexy,2 by which the testicle was placed through an arch of prepubic fascia into the same side of the scrotum. A total of 347 patients had been operated upon for cryptorchism by those surgeons during that time. One hundred forty of those patients were immediately excluded because of their being under 20 yr of age at the time of the survey or for such other reasons as incomplete records or demolished dwellings. The patients were traced either by letter or by a visit to their homes. The letter requested information concerning marital status, length of marriage, and children. RESULTS
A total of 148 letters were sent and 65 patients replied. A visit was made to the homes of 60 patients who failed to reply and 59 patients who had not received an initial letter. Through those visits 27 and 20 patients, respectively, were traced. Out of the total of 207 patients, 112 patients (54~) were successfully traced. It was found that 70% of the patients from Q.M. were successfully traced compared with 42~ success in tracing the patients from P.G.
From St. Mary's Hospital, London, England. Presented before the XXlst International Congress of the British Association of Paediatric Surgeons, Berne, Switzerland, August 27-31, 1974. 9 1975 by Grune & Stratton, Inc. Journal of Pediatric Surgery, Vol. 10, No. 1 (February), 1975
11 5
1 16
P . M . ATKINSON
Table 1. Marital Status and Percentage Paternity of Surgically Treated Cryptorchid Patients
Unilaterally cryptorchid Bilaterally cryptorchid All patients
Single
Married Without Children
Married W i t h Children
34 18 52
10 10 20
32 8 40
Percentage
Paternity 76 44 67
Marital Status and Paternity In this study fertility was judged by "percentage paternity" which is defined here as the percentage of married patients who had become fathers. The survey revealed that 52 patients were single and 60 patients were married. Forty of the married patients had fathered children, indicating an over-all percentage paternity for the series of 67~o (Table 1).
Unilateral Cases Seventy-six patients were traced who had been formerly unilaterally cryptorchid. Forty-two of the patients were married and as 32 of them had sired children, the percentage paternity of the unilateral cases was 76~o.
Bilateral Cases Eighteen of the 36 surgically treated bilaterally cryptorchid patients were married. As only eight of those patients were fathers, the percentage paternity of the bilateral cases was 44~o (Table 1)
Age at Operation All patients in the series were operated upon between the ages of 2.5 and 14 yr, and the over-all average age at operation was 9.3 yr. There was no significant difference in the average age at operation of both unilateral and bilateral groups or between each of the adult status groups.
Age at Survey Table 2 shows the average age of each adult-status group of patients at the time of the survey. The average age of the entire series was 26 yr. It will be seen that the average age of single patients was 24.4 yr. This was significantly different from the average age of married patients with and without children which was 27.6 and 28 yrs, respectively (p < 0.01).
Age at Marriage and Duration of Marriage On consideration of the married patients in this series, Table 3 shows the average age at marriage and duration of marriage at the time of the survey. It will be seen that the average age at which a surgically treated cryptorchid Table 2. Average Age in Years at Survey and Adult Status of Surgically Treated Cryptorchid Patients All Patients
Single
Married Without Children
Married With Children
26
24.2
28
27.6
CRYPTORCHID PATIENTS
1 17
Table 3. Average Age at Marriage and Duration of Marriage in Years at Time of Survey Duration of Marriage at Survey Average Age at Marriage
All Married Patients
Married Without Children
Married With Children
23.4
4.2
3.5
4.5
patient married was 23.4 yr. The duration of marriage of those who had fathered children was on average 1 yr longer than the marriages of those who had not.
Comparison of Results of the Two Hospitals The comparative results of the survey for each hospital are shown in Table 4. Although there is some difference in the percentage paternity results between each hospital, this was not significant. However, the average age at survey of the patients from Q.M. was significantly lower than that of the patients from P.G. (p < 0.01). DISCUSSION
Although it is often stated that unilateral cryptorchism may be part of a bilateral abnormality, 3'4 the results of the unilateral cases in this study are probably quite normal. As there are no figures for percentage paternity in the population as a whole, direct comparison is not possible. It is, therefore, necessary to compare the percentage paternity results of this series of patients with the percentage of fertile marriages for married women in the general population. In 1971, 74~o of women under the age of 45 who had been married for 4 yr, had had fertile marriages. 8 The surgically treated unilaterally cryptorchid patients in this series had been married for an average of 4.2 yr and 76~,, of them had had fertile marriages. This study has, therefore, shown that the fertility of the treated unilaterally cryptorchid patient as judged by percentage paternity, is no different from the population as a whole. The bilateral cases in this study have shown a characteristically diminished paternity of 44~. Although the percentage paternity of all patients in this series conforms with results of previous series, 5-7 the reduction in percentage paternity is entirely due to the poorer results of the bilateral cases. Forty-seven per cent of the patients in this series were single. By comparison, 4 3 ~ of men of similar average age in the general population of 1970 were still single. 9 The average age at marriage of patients in this series and the average age at marriage of bachelors in the general population of 1970 was 24.2 yr and 24.4 yr, respectively. It is likely that the group of patients studied here included a proportion of single men who had not yet considered marriage, and a proporTable 4. Comparative Results for Two Hospitals. Average Age in Years at Survey, Number of Patients, and Percentage Paternity Hospital
Age at Survey
Total Number of Patients
Number of Married Patients
Percentage Paternity
P.G. Q.M.
27.6 24.7
48 64
33 27
70 63
1 18
P . M . AI"KINSON
tion of married men who had not attempted to start a family. The married patients who were childless had on average been married for 1 yr less than those who had become fathers. It is, therefore, possible that the percentage paternity of this group of patients as a whole may increase over the next few years. The important finding of this survey is that 6 7 ~ of the married patients have fathered children. The duration of marriages of the patients who had not sired children was on average 1 yr less than that of those who ltlad, However, the interval between marriage and first live birth in the general population was 1.8 yr L1 which compared with an average duration of childless marriage in this series of 3.5 yr. This tends to confirm the relative degree of infertility which has been shown in the results. On consideration of the age at operation and the eventual paternity results, it has been shown here that an over-all paternity of 67~o is possible even though the average age of all patients at operation was 9.3 yr. There was no difference between the age at operation of the married bilateral patients who had fathered children and of the married bilateral ones who had not, but the numbers of cases were too small in this series to be significant. The patients from P.G. were m o r e difficult to trace than the patients from Q.M. This was partly because of the longer time between operation and survey, and partly because of a difference of locality. M a n y of the patients from P.G. had lived in a central city area which has since been extensively rebuilt, whereas the Q.M. patients mostly lived in a more stable suburban community. The individual long-term results of the two hospitals were similar and there was no significant difference between the over-all percentage paternities from each of the hospitals. In view o f this, it is likely that there is no difference between the ultimate results of the two types of operation performed on patients in this study. SUMMARY
A group of 112 adult patients were traced who had had childhood orchiopexies at an average age of 9 yr at two childrens' hospitals. Sixty-seven per cent of all married patients had sired children although only 4 4 ~o of the married bilateral cryptorchid patients had done so. The percentage paternity of the unilaterally cryptorchid patients was normal when compared with the general population. There appeared to be no difference in the eventual results of the two types of orchiopexy performed on this series of patients. ACKNOWLEDGMENT
I thank Mr. H. H. Nixon and Mr. M. Harmer for their helpful advice and encouragement during the preparation of this paper, and for permission to study their patients. REFERENCES
1. Ombredanne L: Orchiopexie trans3. Scott kS: Unilateral cryptorchidism. scrotale, in Precis Clinique Operatoire de Subsequenteffects on fertility. J Reprod Fertil Chirurgie Infantile. Paris, Masson et Cie, 1923 2:54, 1961 2. Browne D: Treatment of undescended testicle. Proc Roy Soc Med 42:643, 1949 4. Madersbacher M, Kt~vesdi S, Frick J:
CRYPTORCHID PATIENTS
Fertility in unilateral cryptorchidism. Urologe (A)I 1:210, 1972 5. Scott LS: Fertility in cryptorchidism. Proc Roy Soc Med 55:1047, 1962 6. Knauth M, Potempa J: Undescended testes and fertility. Urol lnt 15:77, 1963 7. Albescu JZ, Bergada C, Cullen M: Male fertility in patients treated for cryptorchidism before puberty. Fert Steril 22:829, 1971 8. Registrar General's Statistical Review of England and Wales for the year 1971, Part II, tables volume. Table QQ(c). Family size distribution per 1000 women married once only. London, Her Majesty's Stationery Office, 1973
1 19
9. Registrar General's Statistical Review of England and Wales. Part 11, tables volume. Table K. Proportion of bachelors marrying in each age group per 1000. London, Her Majesty's Stationery Office, 1973 10. Registrar General's Statistical Review of England and Wales. Part 11, tables volume. Table L. Mean age at marriage by previous marital condition. London, Her Majesty's Stationery Office, 1973 11. Woolf M: Lengths of internatal intervals, in Family Intentions. Published by the Office of Population Censuses and Surveys, 1967.
PERATIONS FOR C R Y PT O R C H I S M have an unusual feature in that although the initial anatomic result of orchiopexy is immediately apparent, the functional result of operation may not be known until about 15 or more years later. The study of further series of adults who have had orchiopexies during childhood will help to overcome this remoteness between childhood operation and eventual functional result. The patients in this study came from a limited source of two childrens hospitals in the South of England. A different technique of orchiopexy was used at each of the two hospitals, but the surgeons at both hospitals were aware of the patient with a retractile testicle who will have been largely excluded from the study.
O
MATERIAL AND METHODS
An attempt was made to trace 207 patients who had had childhood orchiopexies at either Paddington Green Children's Hospital, London (P.G.), or Queen Mary's Hospital for Children, Carshalton, Surrey (Q.M.). The operations had been performed between the years 1939 and 1962. Four surgeons or their deputies performed the operations. The majority of patients at P.G. had had Ombredanne's method of orchiopexy? placing the mobilized testicle through the septum into the opposite side of the scrotum. The patients from Q.M. had had the Denis Browne technique of orchiopexy,2 by which the testicle was placed through an arch of prepubic fascia into the same side of the scrotum. A total of 347 patients had been operated upon for cryptorchism by those surgeons during that time. One hundred forty of those patients were immediately excluded because of their being under 20 yr of age at the time of the survey or for such other reasons as incomplete records or demolished dwellings. The patients were traced either by letter or by a visit to their homes. The letter requested information concerning marital status, length of marriage, and children. RESULTS
A total of 148 letters were sent and 65 patients replied. A visit was made to the homes of 60 patients who failed to reply and 59 patients who had not received an initial letter. Through those visits 27 and 20 patients, respectively, were traced. Out of the total of 207 patients, 112 patients (54~) were successfully traced. It was found that 70% of the patients from Q.M. were successfully traced compared with 42~ success in tracing the patients from P.G.
From St. Mary's Hospital, London, England. Presented before the XXlst International Congress of the British Association of Paediatric Surgeons, Berne, Switzerland, August 27-31, 1974. 9 1975 by Grune & Stratton, Inc. Journal of Pediatric Surgery, Vol. 10, No. 1 (February), 1975
11 5
1 16
P . M . ATKINSON
Table 1. Marital Status and Percentage Paternity of Surgically Treated Cryptorchid Patients
Unilaterally cryptorchid Bilaterally cryptorchid All patients
Single
Married Without Children
Married W i t h Children
34 18 52
10 10 20
32 8 40
Percentage
Paternity 76 44 67
Marital Status and Paternity In this study fertility was judged by "percentage paternity" which is defined here as the percentage of married patients who had become fathers. The survey revealed that 52 patients were single and 60 patients were married. Forty of the married patients had fathered children, indicating an over-all percentage paternity for the series of 67~o (Table 1).
Unilateral Cases Seventy-six patients were traced who had been formerly unilaterally cryptorchid. Forty-two of the patients were married and as 32 of them had sired children, the percentage paternity of the unilateral cases was 76~o.
Bilateral Cases Eighteen of the 36 surgically treated bilaterally cryptorchid patients were married. As only eight of those patients were fathers, the percentage paternity of the bilateral cases was 44~o (Table 1)
Age at Operation All patients in the series were operated upon between the ages of 2.5 and 14 yr, and the over-all average age at operation was 9.3 yr. There was no significant difference in the average age at operation of both unilateral and bilateral groups or between each of the adult status groups.
Age at Survey Table 2 shows the average age of each adult-status group of patients at the time of the survey. The average age of the entire series was 26 yr. It will be seen that the average age of single patients was 24.4 yr. This was significantly different from the average age of married patients with and without children which was 27.6 and 28 yrs, respectively (p < 0.01).
Age at Marriage and Duration of Marriage On consideration of the married patients in this series, Table 3 shows the average age at marriage and duration of marriage at the time of the survey. It will be seen that the average age at which a surgically treated cryptorchid Table 2. Average Age in Years at Survey and Adult Status of Surgically Treated Cryptorchid Patients All Patients
Single
Married Without Children
Married With Children
26
24.2
28
27.6
CRYPTORCHID PATIENTS
1 17
Table 3. Average Age at Marriage and Duration of Marriage in Years at Time of Survey Duration of Marriage at Survey Average Age at Marriage
All Married Patients
Married Without Children
Married With Children
23.4
4.2
3.5
4.5
patient married was 23.4 yr. The duration of marriage of those who had fathered children was on average 1 yr longer than the marriages of those who had not.
Comparison of Results of the Two Hospitals The comparative results of the survey for each hospital are shown in Table 4. Although there is some difference in the percentage paternity results between each hospital, this was not significant. However, the average age at survey of the patients from Q.M. was significantly lower than that of the patients from P.G. (p < 0.01). DISCUSSION
Although it is often stated that unilateral cryptorchism may be part of a bilateral abnormality, 3'4 the results of the unilateral cases in this study are probably quite normal. As there are no figures for percentage paternity in the population as a whole, direct comparison is not possible. It is, therefore, necessary to compare the percentage paternity results of this series of patients with the percentage of fertile marriages for married women in the general population. In 1971, 74~o of women under the age of 45 who had been married for 4 yr, had had fertile marriages. 8 The surgically treated unilaterally cryptorchid patients in this series had been married for an average of 4.2 yr and 76~,, of them had had fertile marriages. This study has, therefore, shown that the fertility of the treated unilaterally cryptorchid patient as judged by percentage paternity, is no different from the population as a whole. The bilateral cases in this study have shown a characteristically diminished paternity of 44~. Although the percentage paternity of all patients in this series conforms with results of previous series, 5-7 the reduction in percentage paternity is entirely due to the poorer results of the bilateral cases. Forty-seven per cent of the patients in this series were single. By comparison, 4 3 ~ of men of similar average age in the general population of 1970 were still single. 9 The average age at marriage of patients in this series and the average age at marriage of bachelors in the general population of 1970 was 24.2 yr and 24.4 yr, respectively. It is likely that the group of patients studied here included a proportion of single men who had not yet considered marriage, and a proporTable 4. Comparative Results for Two Hospitals. Average Age in Years at Survey, Number of Patients, and Percentage Paternity Hospital
Age at Survey
Total Number of Patients
Number of Married Patients
Percentage Paternity
P.G. Q.M.
27.6 24.7
48 64
33 27
70 63
1 18
P . M . AI"KINSON
tion of married men who had not attempted to start a family. The married patients who were childless had on average been married for 1 yr less than those who had become fathers. It is, therefore, possible that the percentage paternity of this group of patients as a whole may increase over the next few years. The important finding of this survey is that 6 7 ~ of the married patients have fathered children. The duration of marriages of the patients who had not sired children was on average 1 yr less than that of those who ltlad, However, the interval between marriage and first live birth in the general population was 1.8 yr L1 which compared with an average duration of childless marriage in this series of 3.5 yr. This tends to confirm the relative degree of infertility which has been shown in the results. On consideration of the age at operation and the eventual paternity results, it has been shown here that an over-all paternity of 67~o is possible even though the average age of all patients at operation was 9.3 yr. There was no difference between the age at operation of the married bilateral patients who had fathered children and of the married bilateral ones who had not, but the numbers of cases were too small in this series to be significant. The patients from P.G. were m o r e difficult to trace than the patients from Q.M. This was partly because of the longer time between operation and survey, and partly because of a difference of locality. M a n y of the patients from P.G. had lived in a central city area which has since been extensively rebuilt, whereas the Q.M. patients mostly lived in a more stable suburban community. The individual long-term results of the two hospitals were similar and there was no significant difference between the over-all percentage paternities from each of the hospitals. In view o f this, it is likely that there is no difference between the ultimate results of the two types of operation performed on patients in this study. SUMMARY
A group of 112 adult patients were traced who had had childhood orchiopexies at an average age of 9 yr at two childrens' hospitals. Sixty-seven per cent of all married patients had sired children although only 4 4 ~o of the married bilateral cryptorchid patients had done so. The percentage paternity of the unilaterally cryptorchid patients was normal when compared with the general population. There appeared to be no difference in the eventual results of the two types of orchiopexy performed on this series of patients. ACKNOWLEDGMENT
I thank Mr. H. H. Nixon and Mr. M. Harmer for their helpful advice and encouragement during the preparation of this paper, and for permission to study their patients. REFERENCES
1. Ombredanne L: Orchiopexie trans3. Scott kS: Unilateral cryptorchidism. scrotale, in Precis Clinique Operatoire de Subsequenteffects on fertility. J Reprod Fertil Chirurgie Infantile. Paris, Masson et Cie, 1923 2:54, 1961 2. Browne D: Treatment of undescended testicle. Proc Roy Soc Med 42:643, 1949 4. Madersbacher M, Kt~vesdi S, Frick J:
CRYPTORCHID PATIENTS
Fertility in unilateral cryptorchidism. Urologe (A)I 1:210, 1972 5. Scott LS: Fertility in cryptorchidism. Proc Roy Soc Med 55:1047, 1962 6. Knauth M, Potempa J: Undescended testes and fertility. Urol lnt 15:77, 1963 7. Albescu JZ, Bergada C, Cullen M: Male fertility in patients treated for cryptorchidism before puberty. Fert Steril 22:829, 1971 8. Registrar General's Statistical Review of England and Wales for the year 1971, Part II, tables volume. Table QQ(c). Family size distribution per 1000 women married once only. London, Her Majesty's Stationery Office, 1973
1 19
9. Registrar General's Statistical Review of England and Wales. Part 11, tables volume. Table K. Proportion of bachelors marrying in each age group per 1000. London, Her Majesty's Stationery Office, 1973 10. Registrar General's Statistical Review of England and Wales. Part 11, tables volume. Table L. Mean age at marriage by previous marital condition. London, Her Majesty's Stationery Office, 1973 11. Woolf M: Lengths of internatal intervals, in Family Intentions. Published by the Office of Population Censuses and Surveys, 1967.